Use of medications of questionable benefit in advanced dementia

Abstract

Importance: Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.

Objectives: To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.

Design, setting, and participants: Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.

Main outcomes and measures: Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.

Results: Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.

Conclusions and relevance: Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

Figure 1

Resident-Level Risk Factors and Receipt of Questionably Beneficial Medications Adjusted odds ratios for resident-level factors associated with questionably beneficial medication use among nursing home residents with advanced dementia. Odds ratios were estimated with a generalized estimating equation and a logit link function. Bars represent 95% CIs. ADL indicates activities of daily living.

Figure 2

Facility-Level Risk Factors and Receipt of Questionably Beneficial Medications Adjusted odds ratios for facility-level factors associated with questionably beneficial medication use among nursing home residents with advanced dementia. Odds ratios were estimated with a generalized estimating equation and a logit link function. Bars represent 95% CIs.